Fatty liver disease

Overview

Hepatic steatosis (fatty liver) is an excess accumulation of fat in liver cells. It is very common and is often discovered incidentally on an ultrasound.

The most common cause today is called MASLD — metabolic dysfunction-associated steatotic liver disease. The diagnosis requires steatosis and at least one cardiometabolic factor (abdominal overweight, high blood glucose or diabetes, high blood pressure, high triglycerides or low HDL). You may still come across the old names NAFLD and NASH in reports.

• MASLD — steatosis without significant inflammation.
• MASH — steatosis with inflammation and cell damage, which can lead to fibrosis.

Why it matters

Most people with steatosis do not develop cirrhosis. Two things determine the risk:

1. The degree of fibrosis (scarring) in the liver — the most important indicator of prognosis.
2. Cardiovascular risk — people with MASLD die more often from heart disease than from liver disease.

Symptoms

There are usually no symptoms. Fatigue or heaviness in the right upper abdomen are non-specific.

Causes and risk factors

Overweight (especially around the abdomen), type 2 diabetes, high cholesterol and triglycerides, hypertension. Even people of normal weight can have MASLD. Other causes of steatosis are alcohol, some medications and hepatitis — the doctor rules these out.

Diagnosis

• Ultrasound detects steatosis, but does not measure fibrosis and may miss mild forms.
• Liver tests (ALT, AST) can be normal even when the disease is significant.
• The FIB-4 index — calculated from age, AST, ALT and platelets; it is the first step in assessing the risk of fibrosis.
• Elastography — measures liver stiffness when FIB-4 is not low.
• Biopsy — only in selected cases.

Blood glucose/HbA1c, lipids, blood pressure, alcohol consumption and hepatitis markers are also assessed.

Treatment

Lifestyle is the foundation:

• Gradual weight loss reduces fat and inflammation in the liver. About 5% of body weight reduces steatosis; 7–10% or more can improve inflammation and, in some patients, fibrosis.
• The Mediterranean diet — vegetables, legumes, fish, olive oil, whole grains; limiting sugary drinks and ultra-processed foods.
• Regular physical activity — helps even without major weight loss.
• Alcohol — as little as possible; in advanced fibrosis or cirrhosis, complete abstinence.

Treating associated conditions — diabetes, cholesterol and blood pressure — also protects the heart.

Specific medication: in some countries, drugs have been approved for MASH with a certain degree of fibrosis (e.g. resmetirom and semaglutide). They are not for every steatosis, and approval abroad does not mean they are available or indicated in Albania.

Avoid "detox" products and supplements that promise "liver cleansing" — some of them damage the liver.

Follow-up

The interval between check-ups is set according to the risk of fibrosis and the metabolic condition — for most people, a reassessment every 1–3 years is enough.